Acta Ophthalmologica 2018

Review Article

Cataract frequency and subtypes involved in

workers assessed for their solar radiation exposure:
a systematic review
Alberto Modenese and Fabriziomaria Gobba
Chair of Occupational Medicine, Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio
Emilia, Modena, Italy

ABSTRACT.
exposure. Both UV-A and UV-B are
Cataract is currently the primary cause of blindness worldwide, and one of its absorbed by the lens and act with
main risk factors is solar ultraviolet radiation exposure. According to the different mechanisms in inducing
localization of lens opacities, three main subtypes of cataract are recognized: cataractogenesis, with a progressive
nuclear, cortical and posterior subcapsular cataract. One of the main determi- chronic photochemical damage (West
nants of individual long-term solar radiation exposure is outdoor work. We 1999; L€ ofgren 2016; S€ oderberg et al.
systematically reviewed scientific literature from the last 20 years to update the 2016). The lens nucleus is particularly
recent development of research on the risk of cataract in outdoor workers and on susceptible to UV-A-induced stress,
the specific subtypes involved, also investigating the methods applied to evaluate able to determine changes in the lens
the occupational risk. A total of 15 studies were included in the review, of which fluorescence, increased yellowing and
12 showed a positive association. The studies confirm the relationship of long- loss of pyridine nucleotides (Linetsky
term occupational solar radiation exposure with cortical cataract and give new et al. 2014), by modulating gene
support for nuclear cataract, although no substantial new data were available to expression and apoptotic stimuli in
support a relation with the posterior subcapsular subtype. In most of the studies, the lens epithelial cells (Andley et al.
2000, 2004). Considering UV-B, in
the exposure assessment was not adequate to support a representative evaluation
animal models, it has been showed that
of the ocular risk; however, outdoor work is clearly a relevant risk factor for
in vivo exposure to subthreshold dose
cataract. Further research providing a better evaluation of the relation between of UV-B can induce apoptosis in the
solar radiation exposure levels and lens damage in workers is needed and aimed lens epithelial cells and not in the lens
to establish adequate occupational exposure limits and better preventive fibre cells (Galichanin 2017).
measures, studying also their effectiveness. The two main mechanisms for the
induction of cataracts by ocular UV
Key words: cortical cataract – nuclear cataract – occupational exposure – posterior subcapsular light exposure are oxidative stress and
cataract – solar radiation – ultraviolet radiation its resultant inflammation (Varma
et al. 2011; Øsnes-Ringen et al. 2013)
Acta Ophthalmol. 2018: 96: 779–788 and phototoxidation that may involve
ª 2018 The Authors. Acta Ophthalmologica published by John Wiley & Sons Ltd on behalf of Acta Ophthalmologica photosensitizers (Roberts 2011). These
Scandinavica Foundation.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which
may be endogenous, as metabolites of
permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used inert tryptophan enzymatically modi-
for commercial purposes. fied with age (Balasubramanian 2000)
doi: 10.1111/aos.13734 or UV absorbing advanced glycation
end products (Ortwerth et al. 1997), or
exogenous photosensitizers, for exam-
Introduction approximately 81 million of a total ple phototoxic drugs (Roberts 2002).
number of 246 million cases (Pascolini All of these mechanisms produce reac-
Cataract is currently the primary cause & Mariotti 2012). Different risk factors tive oxygen species (singlet oxygen and/
of blindness worldwide, responsible for are known for this disease, for example or superoxide) which oxidize the lens
approximately 20 million cases, and diabetes (Xu et al. 2016), but one of the proteins, with a progressive formation
the second most prevalent cause of main and most diffused risk factor is of opacities, finally developing into
visual impairment, accounting for long-term ultraviolet (UV) radiation cataracts (Roberts 2011).

779
Acta Ophthalmologica 2018
By large, the most diffuse source of
UV exposure in humans is solar radia-
tion, including the whole range of UV
bands, even if the UV-C and a large part
of UV-B are absorbed in the atmosphere,
mainly by the ozone: the reduction in the
ozone layer, currently ongoing, is
increasing the exposure to UV-B. Other
optical bands included in the solar spec-
trum also have the potential to cause
chronic photochemical lens damage, for
example blue light, particularly in the
presence of phototoxic drugs, but its role
in cataract pathogenesis is less clear
(Taylor et al. 1992; Sliney 2011).
Different cataract classifications
based on morphological and/or etiolog-
ical criteria are available, but in epi-
demiological studies, the most
commonly used is the simplified system
of three types based on the localization
of lens opacities: nuclear cataract is the
most frequent form, followed by cortical
cataract and posterior subcapsular cat-
aract (Hall et al. 1997; Thylefors et al.
2002). This classification has also been
proposed by the World Health Organ-
isation (Thylefors et al. 2002), accord-
ing to whom a significant number of
cataracts can be related to long-term
solar radiation exposure (the upper
population attributable fraction of cor-
tical cataract due to solar radiation is
25%). Furthermore, an increasing body
of scientific data supports the role of
solar radiation in inducing nuclear and
posterior subcapsular cataract (World
Health Organization 2006). Taken as a
whole, this data indicate that a reduc-
tion in excessive long-term solar radia-
tion exposure can lead to the prevention
of a significant number of visual impair-
ments and blindness worldwide, and to a
consequent parallel reduction in medi-
cal costs.
One of the main factors influencing
individual long-term solar radiation
exposure is outdoor work (ICNIRP
2010). Outdoor workers are a large
occupational group, including farmers,
construction workers and others: only
in Europe, the estimated number is
about 14.5 million (European Agency
for Safety and Health at Work 2009;
Modenese et al. 2016). Another rele-
vant aspect to be considered is the
progressive ageing of the working pop-
ulation: cataract is a multifactorial
disease, and its prevalence dramatically
increases with age (Taylor 1999; Abra-
ham et al. 2006; Prokofyeva et al.
2013). Thus, solar radiation exposure
780
in outdoor workers may be a relevant
factor in increasing the prevalence of
cataract and reducing the age of onset.
Nevertheless, this relevant problem
has received little, if any, attention, and
in various countries (e.g. Italy), this
chronic and disabling eye disease is still
not included in the national official lists
of occupational diseases, as well as the
pterygium (Modenese & Gobba 2017).
The aims of this review were to
update the knowledge of recent
research developments concerning the
risk of cataract in outdoor workers,
and also on the specific subtypes
involved. Furthermore, we also focus
on the methods applied to evaluate the
occupational risk related to long-term
ocular solar radiation exposure, which
constitutes one of the main problems of
epidemiological research in this field.
Materials and Methods
An electronic search in accordance with
Preferred Reporting Items for System-
atic Reviews and MetaAnalyses (Liber-
ati et al. 2009) was performed in the
Medline (through PubMed) and Scopus
databases. Limiters were set to include
scientific literature covering a period of
twenty years, from 1st January 1997 to
1st January 2017. The systematic review
was limited to original research articles
with an available English abstract pub-
lished in peer-reviewed journals.
Reviews, case reports, comments or
letters were not considered.
The following search string was
built: [‘cataract’ AND (work* OR
job* OR occupation*) AND (‘outdoor’
OR ‘solar radiation’ OR sunlight OR
UV)].
Two main types of studies were
considered eligible for inclusion, in
case of both longitudinal and cross-
sectional designs:
1 Studies evaluating the presence of
cataracts in groups of outdoor workers,
or in groups of the general population
investigated also for their occupational
solar radiation exposure history.
2 Studies in groups of patients with
cataract, investigated for their occupa-
tional solar radiation exposure history,
or at least classified as mainly outdoor
or indoor workers according to their
specific job.
In this review, only occupational
solar radiation exposure related to
outdoor work is considered. According
to the European Agency for Safety and
Health at Work, outdoor workers are
defined as exposed to solar radiation
for at least the 75% of their working
time, and they are included in a
nonexhaustive list of activities: farmers,
silviculturists and horticulturists, farm
workers, commercial garden and park
workers, postmen and sorters, newspa-
per delivery workers, physical educa-
tion instructors, trainers, coaches and
childcare workers (European Agency
for Safety and Health at Work 2009).
Workers exposed to artificial UV, as
welders etc., have not been considered
in the present review.
In the studies included in this review,
solar radiation exposure was assessed
using different methods: a) simple
qualitative classification according to
the general category of ‘outdoor’ and
‘indoor’ work, or according to the job
performed, compared to the list of
activities of the European Agency; b)
more detailed evaluation of occupa-
tional solar radiation exposure based
on questionnaire data or on measure-
ments. In some group of workers, as
military personnel, policemen and dri-
vers, the exposure is highly variable: in
these subjects, it is not easy to evaluate
the respect of the criterium of the 75%
of the working time exposed to solar
radiation; accordingly, for these job
categories, only studies where exposure
was specifically estimated using ques-
tionnaires or measurements were
included. Another inclusion criterium
is the absence of workers possibly
exposed to artificial optical radiation
sources among controls, that is work-
ers employed in the following sectors
according to the European Commis-
sion: hot industries, such as glass and
metal working; print industries; art and
entertainment sector; medical and den-
tistry sectors in case of use of germici-
dal lamps, LASER treatments, curing
light, cosmetic treatment sector in case
of laser or LED/UV-based treatments,
department stores, pharmaceuticals
and research sectors, but also sewage
treatment sector, using UV germicidal
lamps, other research activities involv-
ing LASER use, metal working sector
involving welding and plastics manu-
facturing involving LASER bonding,
(European Commission, 2011).
Data extraction was performed by
one reviewer and checked by another.
The extraction was performed by read-
ing all of the available abstracts of the

studies returned from the input string
in the two databases. Following this,
full papers were retrieved for all of the
work that met the inclusion criteria.
The reference listings of the selected
papers were also checked to find other
significant research articles.
Results
Study selection
The literature search resulted in 72
items being returned from Medline and
83 from Scopus. After the elimination
of duplicates, 116 articles remained.
The two authors independently exam-
ined the abstracts and agreed on the
studies to be included in the review,
according to the criteria earlier
explained in the Methods section.
Resultantly, 12 studies were selected
and a further three were identified from
the examination of references. A total
of 15 studies were included in the
review (Fig. 1).
Main characteristics of the reviewed
studies and cataract frequency in the
examined samples
Table 1 shows the main characteristics
of the reviewed studies and the cataract
frequencies that were reported, also
detailing the mention of specific catar-
act subtypes. Of the fifteen studies
reviewed, only one had a longitudinal
Records identified through database
search: Medline, n = 121; Scopus n = 126)
Records screened for eligibility
from 1/1/1997 to 1/1/2017
(Medline: n = 72; Scopus: n = 83)
Records after duplicates removed
(n = 116)
Studies included in qualitative
synthesis on cataract and
occupational solar radiation
exposure (n = 15)
Fig. 1. Selection process of the reviewed studies.
design (Mukesh et al. 2006). Nine
studies were cross-sectional with a
case–control design (Ughade et al.
1998; Neale et al. 2003; Saadat &
Farvardin-Jahromi 2006; Pastor-
Valero et al. 2007; Echebiri et al.
2010; Theodoropoulou et al. 2011; El
Chehab et al. 2012; Zarei et al. 2015;
Yu et al. 2016). We also included two
studies in this group conducted in
samples of workers with an exposed/
not exposed design (El Chehab et al.
2012; Yu et al. 2016). Another study
conducted in workers, but without a
control group, was also considered
(Cherian et al. 2015). Four cross-sec-
tional studies were conducted across
relatively large samples of the general
adult population to evaluate cataract
risk factors (Burton et al. 1997;
Athanasiov et al. 2008, 2010; Rim
et al. 2014). In total, eight studies were
conducted in groups of patients with
cataract (Ughade et al. 1998; Neale
et al. 2003; Mukesh et al. 2006; Saadat
& Farvardin-Jahromi 2006; Pastor-
Valero et al. 2007; Echebiri et al.
2010; Theodoropoulou et al. 2011;
Zarei et al. 2015).
Regarding age, only one study in salt
workers (Cherian et al. 2015) included
subjects younger than 40 y/o (mean
41.9). The remaining 14 studies were
conducted in groups of subjects older
than 40, with a mean age between 55
and 60 years in eight studies, between
60 and 65 in two studies and above 65
Additional records identified through
reference examination (n = 3)
Records excluded
(n = 104)
Acta Ophthalmologica 2018
in one study. In three cases, the mean
age data were not available (Table 1).
Considering cataract incidence, eval-
uated in longitudinal study, an overall
5-year incidence of all cataract sub-
types of 20.9% was reported in a
relatively aged group of patients (base-
line mean age 62.5) (Mukesh et al.
2006). In this study, the incidence of
the different subtypes was 16.4% for
nuclear cataract, 7.7% for cortical
cataract and 7% for posterior subcap-
sular cataract.
Considering cataract prevalence in
adults of the general population, the
range varied from 33.2% in central Sri
Lanka (Athanasiov et al. 2010) to
40.4% in central Myanmar (Athana-
siov et al. 2008), compared to a preva-
lence in outdoor workers, ranging from
37.2% in a sample of agricultural
workers from Tibet (Yu et al. 2016)
to 42.4% in mountain guides from
France (El Chehab et al. 2012) and
42.8% in outdoor workers from north
Pakistan (Burton et al. 1997). A lower
prevalence (25.4%) was reported in a
group of younger salt workers in India
(Cherian et al. 2015).
Only 9 of the 15 studies evaluated
the frequency of the cataract subtypes.
Two (Pastor-Valero et al. 2007; Yu
et al. 2016) applied the LOCS II
method (Chylack et al. 1989), four
(Athanasiov et al. 2008, 2010; El Che-
hab et al. 2012; Rim et al. 2014) the
LOCS III method (Chylack et al.
1993), and three (Neale et al. 2003;
Mukesh et al. 2006; Theodoropoulou
et al. 2011) used other methods. Fur-
thermore, four studies included ‘mixed
type’ cataracts in their classification
(Mukesh et al. 2006; Pastor-Valero
et al. 2007; Rim et al. 2014; Yu et al.
2016), while the other studies classified
only pure forms (cortical, nuclear and
posterior subcapsular).
Nuclear cataract was the most fre-
quent subtype reported in six studies
(Neale et al. 2003; Mukesh et al. 2006;
Pastor-Valero et al. 2007; Athanasiov
et al. 2008; Theodoropoulou et al.
2011; Rim et al. 2014), with cortical
cataract featuring most prominently in
the other three (Athanasiov et al. 2010;
El Chehab et al. 2012; Yu et al. 2016).
Considering subtype prevalence in the
general population, the nuclear form
ranged from 4.5% in central Sri Lanka
(Athanasiov et al. 2010) to 28% in east
Australia (Neale et al. 2003), the cor-
tical subtype from 7.4% in South
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Table 1. Main characteristics of the studies reviewed and cataract frequency in the examined samples.

Subjects groupsample size

1st Author, year Place (n)/mean age (years) Cataract frequency (%) and subtypes considered

Longitudinal
Mukesh et al. (2006) Victoria State, south-east PtA/2392/62.5 (at baseline) Overall 5-years incidence = 20.9 (ACS) 7.7 (CC)
Australia 16.4 (NC) 7 (PSC)
Cross-sectional/Case–control Prevalence
Yu et al. (2016) East and West (Tibetans Wo/813/58.1 - For ACS: 25.8 (East Province) and 37.2 (Tibet)
mountains) China (s.d., p < 0.001)
for NC: 6.5 (East Province) and 6.1 (Tibet)
- For CC: 17.9 (East Province) and 0.9 (Tibet)
- For PSC: 0.2 (East Province) and 6.5 (Tibet)
- For mix types: 1.2 (East Province) and 23.8 (Tibet)
Zarei et al. (2015) Shiraz, South Iran PtA/380/62.5 /(ACS)
El Chehab et al. (2012) Chamonix (mountain) and Wo/186/59.5 - For ACS: 29.8; 42.4 in OW (s.d., p < 0.01)
Lyon (plane), France - For CC: 20.7; 30.8 in OW (s.d., p < 0.01)
- For NC: 4.6; 3.7 in OW (s.d., p < 0.01)
- For PSC: 1.7; 2.7 in OW (n.s.d)
Theodoropoulou et al. Athens, Greece PtA/628/n.av. (Range: 46– Subtype frequency (%) among ACS = 66.8 (NC)
(2011) 85) 14.6 (CC) 19.4 (PSC)
Echebiri et al. (2010) Lagos, south-west and PtA/1060/n.av. (Range: 40– n.av./(ACS)
Kano, north-central 89)
Nigeria
Pastor-Valero et al. Valencia, Spain PtA/677/66.3 Subtype frequency (%) among ACS = 30 (NC) 12
(2007) (CC) 18.9 (PSC) 39 (mixed)
Saadat & Farvardin- Shiraz, South Iran PtA/190/63.9 n.av./(ACS)
Jahromi (2006)
Neale et al. (2003) Brisbane, East Australia PtA/355/57.9 36.8 (ACS) 8 (CC) 28 (NC) 0.6 (PSC)
*p based on a sample of 1555 subjects from which
the NC cases have been extracted for the study
Ughade et al. (1998) Nagpur, central India PtA/524/n.av. (Range n.av., n.av./(ACS)
majority 51–70)
Cross-Sectional
Cherian et al. (2015) Marakkanam, south India Wo/331/41.9 25.4 (ACS)
Rim et al. (2014) South Korea GP(A)/11591/58.4 40.1 (ACS) 7.4 (CC) 20.3 (NC) 0.3 (PSC) 7.5 (mixed)
Athanasiov et al. (2010) Central Sri Lanka GP(A)/1375/56.3 33.2 (ACS) 26.1 (CC) 4.5 (NC) 8.0 (PSC)
Athanasiov et al. (2008) Central Myanmar GP(A)/2044/57.9 40.4 (ACS) 20.9 (CC) 27.4 (NC) 11.3 (PSC)
Burton et al. (1997) North Pakistan GP(A)/797/55.6 36.3 (ACS); 42.8 in OW (n.s.d)

ACS = all cataract subtypes, CC = cortical cataract, GP(A) = general population (Adults), NC = nuclear cataract, n.av. = no available data,
n.s.d. = no significant difference, OW = outdoor workers, PSC = posterior subcapsular cataract, PtA = patients (Adults), s.d. = significant
difference, Wo = workers.

Korea (Rim et al. 2014) to 26.1%
(Athanasiov et al. 2010), and posterior
subcapsular cataract prevalence ranged
from 0.3% (Rim et al. 2014) to 11.3%
in central Myanmar (Athanasiov et al.
2008).
The subtype prevalence in outdoor
workers was investigated in only two
studies (El Chehab et al. 2012; Yu
et al. 2016), and with uneven results
(L€ofgren 2016). In a group of farmers
living at low altitude in East China,
cortical cataract was the most frequent
subtype, but in another group living at
high altitude in the Tibetan mountains,
mixed types had a much higher preva-
lence (18% versus 1% for cortical and
1% versus 24% for mixed type, respec-
tively) (Yu et al. 2016). In French
mountain guides working at high alti-
tudes, the most frequent subtype was
the cortical one (prevalence 30.8%),
but the mixed type cataracts were not
classified, and the prevalence of nuclear
and posterior subcapsular cataracts
was, respectively, 3.7 and 2.7% (El
Chehab et al. 2012).
Working categories and main methods
adopted for occupational solar radiation
exposure assessment
Table 2 shows the different working
categories with sunlight exposure con-
sidered in the reviewed studies, and the
main methods adopted to evaluate
occupational solar radiation exposure.
As anticipated in Table 1, only three
studies (El Chehab et al. 2012; Cherian
et al. 2015; Yu et al. 2016) were specif-
ically conducted in groups of outdoor
workers. Furthermore, all of the studies
evaluated occupational Sun exposure
using different methods which are
scarcely comparable. The methods used
to assess occupational solar radiation
exposure at work in the collected stud-
ies can be classified into five main types:
1 Working category: the authors arbi-
trarily classified activities as solar radi-
ation exposed – outdoor workers or
not exposed. This is the most fre-
quently adopted method and features
in six of the 15 studies (Mukesh et al.
2006; Saadat & Farvardin-Jahromi
2006; Athanasiov et al. 2008, 2010;
Cherian et al. 2015; Zarei et al. 2015).
2 Simple question(s): subjects were
classified as outdoor workers based
on the number of hours usually spent
working outdoors, which was assessed
with one or a few simple questions
(Ughade et al. 1998; Echebiri et al.

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Table 2. Occupational solar radiation exposure and cataract.
Main method applied to evaluate solar radiation
exposure
Classification of the exposed workers based on
their working category (e.g. outdoor versus
indoor)
Classification of occupational solar radiation
exposure based on a (few) simple question(s)
(e.g. how many hours usually spent outdoor per
day?)
Evaluation of solar radiation exposure based on
environmental data (e.g. UV levels measured
with radiometers or obtained from databases)
Detailed questionnaire-based solar radiation
exposure evaluation (e.g. including information
on exposure history and adoption of protective/
risky habits)
Comprehensive evaluation of solar radiation
exposure based on both subjective and objective
data (e.g. a detailed questionnaire-based
investigation + environmental data or individual
exposure data)
2010; Theodoropoulou et al. 2011;
Rim et al. 2014).
3 Environmental data: specific charac-
teristics of the workplace were collected.
These included for example the altitude
and the presence of UV-reflecting fresh
snow for working in mountain areas;
meteorological data on solar radiation
(e.g. irradiance); and spot UV measure-
ments (Burton et al. 1997).
4 Questionnaire-based evaluation: this
group included studies based on
detailed questionnaires, aimed to eval-
uate different aspects of long-term
occupational exposure to solar radia-
tion. Only two such studies were found.
In a French study on mountain guides
(El Chehab et al. 2012), the question-
naire considered various items, such as
the number of days skiing per year, the
number of days worked above 5000 m,
the percentage of activity between 1000
and 3000 m of altitude, the percentage
of activity on snow, the type of eye
protection used, and the time wearing
protection during working activities. In
an Australian study limited to nuclear
cataract cases (Neale et al. 2003), expo-
sure during various decades of working
life (20–29, 30–39, 40–49, 50–59,
>60 years) and the use of protective
sunglasses were assessed and the results
were merged to classify the subjects
into three groups: low, medium or high
lifetime solar radiation exposure.
Study (1st Author, year)
Athanasiov et al. (2008)
Athanasiov et al. (2010)
Cherian et al. (2015)
Mukesh et al. (2006)
Saadat & Farvardin-Jahromi (2006)
Zarei et al. (2015)
Ughade et al. (1998)
Echebiri et al. (2010)
Rim et al. (2014)
Theodoropoulou et al. (2011)
Burton et al. (1997)
El Chehab et al. (2012)
Neale et al. (2003)
Pastor-Valero et al. (2007)
Yu et al. (2016)
5 Integrated estimate of the exposure:
two studies developed an articulated
method to estimate the cumulative
long-term occupational solar radiation
exposure, integrating subjective and
objective data. A Chinese study (Yu
et al. 2016) combined data on the
number of hours spent working out-
door, collected by a short questionnaire
and also environmental data relating to
erythema annual UV irradiance, to
build a cumulative exposure index. A
Spanish study (Pastor-Valero et al.
2007) elaborated another example of
cumulative exposure index, based on a
more detailed subjective evaluation
considering the mean number of daily
and weekly outdoor working hours, the
total number of employment years and
the use of protective equipment, and
also on collected data on UV environ-
mental irradiance based on measure-
ments performed with dosimeters and
meteorological databases.
Results of the association between
occupational solar radiation exposure and
cataract, considering the main subtypes
involved
Table 3 shows the results of the asso-
ciation between occupational solar
radiation exposure and cataract, also
considering the main subtypes
involved.
Acta Ophthalmologica 2018
Working group(s) studied
Agricultural workers
Agricultural workers
Salt workers
Labourers
Outdoor workers
Outdoor workers
Outdoor workers
Outdoor workers
Agricultural workers, forester, fishermen,
labourers
Outdoor workers (agricultural workers + others)
Outdoor workers (AW + LB)
Mountain guides
Outdoor workers
Outdoor workers
Agricultural workers
All cataract subtypes
Considering all the subtypes of catar-
act, 12 of the 15 studies found a
positive association with occupational
solar radiation exposure. In particular,
the only longitudinal study (Mukesh
et al. 2006) found a positive adjusted
relative risk of 2.2 for the general
category of outdoor workers defined
as ‘labourers’. Three cross-sectional
studies found a significant positive
odds ratio (OR) adjusted for various
covariates such as age, gender, smok-
ing habit and education (Theodor-
opoulou et al. 2011; Rim et al. 2014;
Yu et al. 2016). The highest OR was of
2.61 for Chinese agricultural workers
with a UV annual exposure higher than
2700 joules per square-metre, based on
a semi-quantitative evaluation (Yu
et al. 2016). A Spanish study (Pastor-
Valero et al. 2007) found an adjusted
OR of 1.19, considering also the use of
protecting equipment, but the confi-
dence interval was not significant.
Another four studies (Ughade et al.
1998; Saadat & Farvardin-Jahromi
2006; Echebiri et al. 2010; Zarei et al.
2015) found positive associations with
significant crude ORs ranging from 1.7
(Zarei et al. 2015) to 5.9 (Echebiri et al.
2010). In two studies from Iran (Saadat
& Farvardin-Jahromi 2006; Zarei et al.
2015), a specific association with catar-
act was found in outdoor workers with
783
Acta Ophthalmologica 2018

Table 3. Main results of the studies reviewed considering occupational solar radiation (SR) exposure and cataract.

Other cataract risk factors

1st Author, year Results concerning cataract (subtypes) and occupational SRE considered

Longitudinal
Mukesh et al. (2006)
Cross-Sectional/Case–Control
Yu et al. (2016)
Zarei et al. (2015)
El Chehab et al. (2012)
Theodoropoulou et al. (2011)
Echebiri et al. (2010)
Pastor-Valero et al. (2007)
Saadat & Farvardin-Jahromi
(2006)
Neale et al. (2003)
Ughade et al. (1998)
Cross-Sectional
Cherian et al. (2015)
Rim et al. (2014)
Athanasiov et al. (2010)
Athanasiov et al. (2008)
Burton et al. (1997)
RR(adj) for CC = 2.2 (1.03–4.9) A, G, DB, SM, ORF (myopia,
vitamin intake)
OR (cr) (ACS) = 2.45 [1.56-3.81] A, G, Edu, SM, AC, ORF
OR (adj) (ACS) = 2.61 [1.45-4.67] (fruit–vegetable intake)
OR (cr) (ACS) = 1.7 [1.0–2.8] A, G
ACS* = 2.7 [1.2–6.3] (OW with particular gene polymorphism)
P (ACS, CC): MG (higher) vs controls (p < 0.01) A, G
P (NC): MG (lower) vs controls (p < 0.01)
OR (cr)
Working on snow: ACS = 1.1 [1.03–1.17];
CC = 1.07 [1.01–1.15]
Wearing ski mask at work: ACS = 0.5 [0.26–0.96]
Working at >3 km: ACS = 1.05 [1.01–1.09]; CC = 1.05 [1.01–1.09]
Photochromic lenses: ACS = 0.53 [0.29–0.96];CC=0.47 [0.25–0.9]
OtRe: higher frequency of lens micro-
opacities (p < 0.01) and higher lens
density (p = 0.01) in MG
OR (adj) (ACS) = 2.03 [1.32–3.12] A, G, SM, BMI, DB, AC, NOSRE,
(CC) = 1.74 [0.77–3.96] ORF (familiarity, drugs)
(NC) = 1.77 [1.10–2.85]
(PSC) = 2.84 [1.41–5.72]
OR (cr) (ACS) = 1.8 [1.5–2.9] in Lagos (urban contest) A, G, SM, Edu; BMI; AC
= 5.9 [4.8–6.9] in Kano (rural contest)
OR (adj) (ACS) = 0.99 [0.57–1.73]; 1.19 [0.69–2.03]* A, G, SM, AC, Edu, ORF
(NC) = 3.68 [1.50–9.01]; 3.19 [1.24–8.21]* (serum levels of antioxidants)
(CC) = 0.67 [0.22–2.00]; 1.19 [0.78–1.09]*
(PSC) = 0.57 [0.22–1.45]; 0.57 [0.20–1.60]*
OR (cr) (ACS) = 1.46 [0.52–4.04]† A, G
OR (cr) (NC) = 2.8 (1.39–5.63)‡; 2.18 (1.15–4.11)§ A, G, Edu, SM,
=1.59 (0.84–3.01)¶ DB, NOSRE
OR (adj) (NC) = 2.9 (1.14–7.6)‡; 2.11 (0.74–5.98)§
=1.61 (0.70–3.71)¶
OR (cr) (ACS) = 2.75 [1.52–4.97] A, G, BMI, Edu, DB, AC, SM,
OR (adj) (ACS) = 1.87 [0.94–3.71] ORF (glaucoma, myopia,
familiarity, drugs)
P (ACS) = 25.4% /
OR (cr) (ACS) = 6.8 [5.6–8.3]k; 3.6 [2.9–4.4]**; 1.7 [1.6–1.9]†† A, G, AC, BMI, DB, SM, Edu, NOSRE
OR (adj) (ACS) = 1.1 [0.8–1.4]k; 1.1 [0.8–1.4]**; 1.1 [1.0–1.2]††
N.A A, G, SM, Edu; BMI, DB
OR(adj) (ACS) = 0.9 [0.6–1.4]; A, G, SM, Edu; BMI
(NC) = 1.0 [0.6–1.8];
(CC) = 0.70 [0.3–1.7];
(PSC) = 0.9 [0.3–2.9]
P (ACS): higher in male OW living in A, BMI
areas with lower UV irradiance (p < 0.00l)

A = age, AC = alcohol consumption, ACS = all cataract subtypes, AW = agricultural workers, BMI = body mass index, CC = cortical cataract,
CI = confidence interval, DB = diabetes, Edu = education, G = gender, LB = labourers, MG = mountain guides, NA = no association, NC = nu-
clear cataract, NOSRE = nonoccupational solar radiation exposure, OR (adj) = adjusted odd ratio [95% CI], OR (cr) = crude odds ratio [95% CI],
ORF = other risk factors (to be specified), OtRe = other results, OW = outdoor workers, P = prevalence, PSC = posterior subcapsular cataract, RR
(adj) = adjusted relative risk [95% CI], SM = smoking history, SRE = solar radiation exposure, SW = salt workers.
* Considering also the use of protective equipment.
†
OW with null genotype of glutathione S-transferase M1 – OR (cr).
‡
Medium exposure group.
§
High exposure group.
High exposure and low sunglasses use group.
k
AW + fishermen + forester.
** LB.
††
SRE ≥ 5 hr/day.

784

particular genetic polymorphisms. A
Pakistani study (Burton et al. 1997)
showed a higher prevalence of cataract
in male outdoor workers (p < 0.001),
while a French study (El Chehab et al.
2012) on mountain guides found a
higher prevalence of cataracts in these
workers (p < 0.01) and also a higher
frequency of micro-opacities of the lens
(p < 0.01) and higher lens density
(p = 0.01). Only two studies (Athana-
siov et al. 2008, 2010) stemmed from
the same research group (one con-
ducted in Sri Lanka and one in Myan-
mar on two large general population
groups) found no association between
cataract and occupational solar radia-
tion exposure. Finally, an Indian study
on salt workers (Cherian et al. 2015)
evaluated only the prevalence of catar-
acts (25.4% in a group of outdoor
workers) and did not offer any further
possible associations, and an Aus-
tralian study (Neale et al. 2003) did
not consider types of cataracts other
than the nuclear forms.
Specific cataract subtypes: nuclear, corti-
cal and posterior subcapsular cataracts
Six studies evaluated the association
between nuclear cataract and occupa-
tional solar radiation exposure. Three
found significant positive adjusted
ORs. These ranged from 3.68 in a
Spanish study (Pastor-Valero et al.
2007) (the OR was reduced to 3.19
considering the use of protective equip-
ment), 2.9 for outdoor workers with a
medium solar radiation exposure in an
Australian study (Neale et al. 2003)
and 1.77 in a Greek study (Theodor-
opoulou et al. 2011). However, in three
studies, no association was observed
(Athanasiov et al. 2008, 2010; El Che-
hab et al. 2012).
Five studies evaluated the associa-
tion between cortical cataract and
occupational solar radiation exposure.
Two European studies conducted in
Spain (Pastor-Valero et al. 2007) and
Greece (Theodoropoulou et al. 2011)
found a positive adjusted OR for
occupational solar radiation exposure,
but the confidence interval was not
significant. A French study on moun-
tain guides (El Chehab et al. 2012)
found a higher prevalence of cortical
cataract compared to the not exposed
group (p < 0.01). This subtype was
also positively associated with working
on snow and with working at an
altitude higher than 3,000 metres,
respectively, with significant crude
ORs of 1.07 and 1.05. Furthermore,
the use of photochromic lenses was
negatively associated (OR=0.47). In
two studies from the same group, no
association was observed (Athanasiov
et al. 2008, 2010).
Finally, five studies evaluated poste-
rior subcapsular cataract (Pastor-
Valero et al. 2007; Athanasiov et al.
2008, 2010; Theodoropoulou et al.
2011; El Chehab et al. 2012), but only
in a Greek study (Theodoropoulou
et al. 2011), an adjusted positive OR
of 2.84 was found for outdoor workers.
Discussion
General overview of the studies and
limitations of the systematic review
The quality of the analysis performed in
the studies is rather inhomogeneous,
and some weaknesses can be observed.
However, considering the scarce num-
ber of studies which have been pub-
lished on the topic, to analyse all the
associated literature of interest, we
decided not to exclude any pertinent
study. Another problem is that the
study designs applied by the researchers
are quite different and, hence, scarcely
comparable. This therefore precludes
any possibility of conducting a meta-
analysis. As an example, for the clas-
sification of lens opacities, the major-
ity of the studies applied the Lens
Opacity Classification System (Chy-
lack et al. 1989, 1993) but used differ-
ent versions, and a few studies also
considered a mixed cataract subtype.
But, the most important cause of
inhomogeneity found in the reviewed
studies was the method used to evaluate
occupational solar radiation exposure.
Notably, only two studies had devel-
oped a semi-quantitative index of cumu-
lative exposure (Pastor-Valero et al.
2007; Yu et al. 2016), and only one
considered parameters influencing ocu-
lar exposure, such as the use of sun-
glasses (Pastor-Valero et al. 2007). All
of the other remaining studies classified
solar radiation exposure according to
different, and scarcely comparable
methods, and, in some cases, simply as
‘outdoor’ and ‘indoor’ activities based
on a theoretical list. As artificial UV
exposure was not considered in this
study, any potential occupational expo-
sure in cases, and/or in controls, was
considered exclusion criteria.
Acta Ophthalmologica 2018
Another possible problem, not con-
sidered in the studies included in this
review, is the potential role of occupa-
tional eye injuries in cataract induction:
this may represent a possible limita-
tion; on the other hand, traumatic
cataract is usually related to significant
blunt or penetrating ocular trauma that
currently are relatively rare in outdoor
workers according to our recent data
(Gobba et al. 2017).
Associations between cataract, its main
subtypes and occupational solar radiation
exposure
To discuss the results of our review
considering the association between
cataract, its main subtypes and occu-
pational solar radiation exposure, we
would like to start from the main
results of a 2002 review (McCarty &
Taylor 2002) that considered 22 epi-
demiologic studies on humans pub-
lished from 1977 to 2000. Of these,
nine evaluated occupational solar radi-
ation exposure (one of these from
Burton et al. (1997) is included also in
this review). The conclusions of
McCarty & Taylor were that the
majority of the epidemiological studies
reviewed supported an association
between UV-B and the development
of cortical cataract and perhaps poste-
rior subcapsular cataract.
Fifteen years on, the results of our
systematic review confirm that there is
a solid association between occupa-
tional solar radiation exposure in out-
door workers and cataract
development. Twelve of the 15 studies
found a positive association, and
specifically, one longitudinal study
found a significant adjusted relative
risk in labourers, taking into account
also leisure solar radiation exposure
(Mukesh et al. 2006), and five studies
found positive adjusted ORs for catar-
act or at least for one subtype (Neale
et al. 2003; Pastor-Valero et al. 2007;
Theodoropoulou et al. 2011; Rim et al.
2014; Yu et al. 2016).
Regarding the cataract subtypes,
the nuclear form is confirmed to be
the most frequent subtype of age-
related cataract, followed by cortical,
and with posterior subcapsular as the
least frequent. The major recent evi-
dence for a causal relationship
between occupational solar radiation
exposure and cataract has been found
for the nuclear subtype, with three
785
Acta Ophthalmologica 2018
positive adjusted ORs (Neale et al.
2003; Pastor-Valero et al. 2007;
Theodoropoulou et al. 2011), followed
by the cortical form with three studies
finding positive unadjusted associa-
tions (Pastor-Valero et al. 2007;
Theodoropoulou et al. 2011; El Che-
hab et al. 2012), and posterior sub-
capsular cataract with a single positive
adjusted OR (Theodoropoulou et al.
2011). Considering this, the reviewed
data confirm the association between
occupational solar radiation exposure
and cortical cataract, while new evi-
dence of a relationship between the
nuclear subtype and long-term occu-
pational solar radiation exposure has
been added from recent scientific lit-
erature. It has to be particularly noted
that the oxidative mechanism for the
formation of nuclear cataracts differs
from that of cortical cataracts: the
paper from Neale et al. suggests that
the majority of UV-induced lens dam-
age occurs before 30 years of age in
the cortical lens fibres progressively
pushed to the centre of the nucleus
with the ageing of the lens, supporting
the role of a cumulative effect of
occupational solar radiation exposure,
especially if started at early ages.
Finally, the data on PCS are less
conclusive: this form is typical, for
example, of subjects with a history of
chronic use of steroid drugs or with
specific ocular comorbidities (Andjelic
et al. 2017), while no clear association
with outdoor work emerges.
Regarding the prevalence of cataract
in outdoor workers, with the exception
of the Indian study that included
younger workers, in our review, we
found prevalence of around 40%. Sim-
ilar prevalence can be observed in
general adult populations living at
low latitude in Asia, Africa, South
America and Oceania, while in Europe,
the prevalence is approximately half
(Taylor 1999; McCarty & Taylor 2002;
Abraham et al. 2006; WHO 2006;
Prokofyeva et al. 2013). This suggests
that outdoor work is a relevant factor
in influencing the development of
cataract in particular where levels of
environmental UV irradiance are
lower, while its influence is less signif-
icant at higher environmental UV
levels. This observation is supported
by the data of Burton et al., showing a
significant association of cataract in
outdoor workers living in areas with
lower UV irradiance, but not in
786
another group living at high altitude
(Burton et al. 1997).
Occupational solar radiation exposure
assessment and cataract
One of the main objectives of this
review was also to identify the main
methods applied to evaluate long-term
ocular exposure to solar radiation in
outdoor workers. Unfortunately, we
did not find any significant advances
in the modelling of cumulative solar
radiation exposure assessment, in par-
ticular considering the different optical
radiation bands that are able to induce
photochemical damage of the lens. The
methods theorized by McCarty, Rosen-
thal, Taylor, West and others and
applied in various North American
and Australian studies in the early
1990s (Taylor 1989; Rosenthal et al.
1991; Taylor et al. 1992; McCarty
et al. 1996; West et al. 1998) are still
the most precise methods in evaluating
long-term cumulative sunlight expo-
sure, and, in particular, in estimating
the UV-B dose reaching the lens. Only
two studies in this review adopted
semi-quantitative methods to evaluate
occupational long-term solar radiation
exposure. Yu et al. elaborated a simple
cumulative exposure index based on
the subjective assessment of the mean
daily hours spent outdoors, and the
average environmental annual ery-
thema UV exposure based on meteo-
rological databases. However, they did
not further consider exposure of the
eye and the role of different UV bands.
The Spanish study of Pastor-Valero
et al. elaborated a cumulative solar
radiation exposure index integrating
data from a detailed interview and
combined with dosimeter-based UV
environmental irradiance measure-
ments and data from meteorological
databases. This study currently offers
the most detailed cumulative exposure
assessment, even if no measurement of
individual ocular exposure considering
different UV bands (and including blue
light) has been performed. Neverthe-
less, the strength of the Spanish study
(Pastor-Valero et al. 2007), as well as
of the French (El Chehab et al. 2012),
the Greek (Theodoropoulou et al.
2011) and the two Australian studies
(Neale et al. 2003; Mukesh et al. 2006)
included in this review, is the consider-
ation of protective measures, and in
particular of the use of sunglasses and
their possible role in preventing catar-
act in outdoor workers. For ocular
exposure, albedo (the fraction of solar
energy reflected from the Earth) is a
relevant phenomenon (International
Commission on Non-Ionizing Radia-
tion Protection, 2010), but only the
French study has considered the role of
the snow in this respect, reflecting up to
90% of UV rays.
Lastly, and as previously mentioned,
the differences in methods used to eval-
uate occupational solar radiation expo-
sure have limited the possibility of
undertaking a more detailed analysis of
the relationship between the main factors
influencing ocular lens exposure to sun-
light (e.g. altitude, reflective surfaces,
protective equipment), and the frequency
of cataract in outdoor workers.
Conclusions
In our systematic review of the last
20 years of related scientific literature,
we found 15 studies evaluating the
frequency and association of cataract
with occupational solar radiation expo-
sure. A positive association was
observed in 12 of these studies, con-
firming the role of outdoor work as a
relevant risk factor for cataract, and so
supporting the need to include this
disease among occupational diseases
for both preventive purposes and also
from the perspective of workers’ com-
pensation. The studies also confirm the
relation of long-term occupational
solar radiation exposure with cortical
cataract but give also new support for
nuclear cataract, although no substan-
tial new data have been found on the
relation with posterior subcapsular
cataract. As a final observation, in the
last 20 years, only a few studies con-
cerning cataract in workers exposed to
solar radiation have been published,
and in most of the studies, the exposure
assessment was inadequate for a repre-
sentative evaluation of the ocular risk,
and the classification of the types of
cataracts applied is lacking in homo-
geneity. Another problem is an inade-
quate/incomplete consideration of
known risk factors.
For the abovementioned reasons,
there is considerable scope for further
research in this field. Among relevant
aspects to be considered for a signifi-
cant advancement of the knowledge in
this field, at least the following deserve
specific attention:

1 In the exposure evaluation, lifetime
ocular exposure to ultraviolet radia-
tion must be considered, including
both occupational and leisure time,
possibly integrating objective data
available through databases, as local
UV Index or other meteorological
data, and/or also field measurements,
with subjective data obtained from
questionnaires.
2 The individual protective habits that
may influence ocular UV exposure must
be investigated, including for example
frequency of use and characteristics of
the hats and sunglasses adopted (shape,
types of UV filters, etc.).
3 Individual relevant clinical informa-
tion that can integrate the UV exposure
history, as a detailed anamnesis on the
episodes of skin erythema and sunburns
in childhood and as adults, on the
intake of photosensitizing drugs (e.g.
antibiotics, antimalarials,) and others.
4 Cataract in future studies deserves a
better characterization, for example
diagnosis should be based on slit lamp
examinations, possibly including also
OCT images, and the classification and
description of cataract morphology
should be standardized using adequate
methods, as the LOCS, enabling a
better comparison of the evidence.
In our opinion, studies with these
characteristics will lead to a better
comprehension of the relationship
between solar radiation exposure levels
and lens damage in outdoor workers,
possibly enabling the development of
adequate occupational exposure limits
and of a more effective prevention.
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Received on March 26th, 2017.
Accepted on January 22nd, 2018.
Correspondence:
Alberto Modenese, MD, PhD
Department of Biomedical, Metabolic and
Neural Sciences
University of Modena & Reggio Emilia
via G. Campi 287 – 41125
Modena
Italy
Tel: +390592055475
Fax: +390592055770
Email: alberto.modenese@unimore.it